Willing to go with what works
Whether it is embracing the traditional 12 Steps or implementing medication in treatment, a majority of clinicians share a common mindset: If it works for the patient, run with it.
More than four out of five participants in Addiction Professional’s third annual Quality of Life Survey expressed a positive opinion on the 12 Steps, while nearly 90% of respondents shared favorable views on medication-assisted treatment (MAT).
“I’ve come to decide that whatever is working for the individual, as long as it’s helpful and not causing harm, go for it,” says Jessica Holton, a licensed clinical social worker in private practice in Greenville, N.C., who participated in the 2017 survey.
Responses to questions regarding both the 12 Steps and MAT were mostly in line with results from the survey conducted in 2016.
The 2017 edition, which was conducted in September, drew responses from more than 650 clinicians. The survey is open to all clinicians in the field, and therefore, the individuals who have participated have varied from year to year.
Willing to work the Steps
A majority of clinicians who participated in the survey incorporate the 12 Steps into their treatment plans to at least some degree, as 48.1% said they feel it’s a key element at all levels of treatment and 34% said it was best for continuing care. Just 15.7% said it was time to phase out the Steps. Most notably, 6% fewer participants said the 12 Steps are a key element at all levels of care compared to the previous year, but there was a 3% increase in those who felt the Steps were best for continuing care.
When applicants arrive at The Extension Recovery Services, they know from Day One that the 12 Steps are the basis of the Marietta, Ga.-based treatment center’s program, says Robert Jordan, CAC, director of The Extension’s men’s program.
“Coupled with the treatment we have, it gets them used to the part of the continuum of care once they transition out of treatment,” says Jordan, who has spent all nine years of his career at The Extension Recovery Services. “They’re set up, and they know the importance of having support.”
Lyle Fried, CAP, ICADC, CHC, co- founder and CEO of The Shores Treatment and Recovery in Port St. Lucie, Fla., says he finds value in implementing pieces of the Steps into a cognitive behavioral therapy approach.
“I ask people, ‘Do you think you need community or accountability in your life?’ ” says Fried. “Inevitably, they’ll say yes, and I’ll tell them, ‘Even if you believe nothing else that they teach there, they provide at least that.”
Fried, who is in long-term recovery after battling a poly-substance use addiction stemming from trauma, says he initially found little value in the Steps. Fried’s sponsor, his group leader and Fried himself all experienced a recurrence of their substance use, causing him to believe the Steps weren’t helpful at all. Fried says his feelings on the Steps evolved, however, once he found success with another faith-based approach to recovery. He reinvestigated the Steps and found that much of what worked for him was similar to the 12 Steps.
Fried says many of those in recovery who walk away from the 12 Steps do so because of the way some groups today interpret the fourth step.
“Nowadays, why do you think we have that 1-2-3 shuffle of people doing the first Steps, and then Step 4, it’s a daunting, shaming task, and they relapse in the process of it?” Fried says.
“The original fourth step was just what it said it was: Searching and fearless moral inventory of ourselves. We use different words today. People early in their recovery aren’t ready for the guilt and shame that come with that.
“But, as a cognitive behavioral therapist, I would ask somebody what are their strengths and weaknesses, and how can we use these strengths to overcome these weaknesses? That’s a normal process and why we include those kinds of questions in a bio-psycho-social evaluation.”
The 12 Steps, meanwhile, are not typically a focal point of discussions with clients for Holton, a practitioner for nearly 20 years. Holton says she recognizes the 12 Steps are important for some individuals in recovery, but that her work with clients focuses more on the neuroscience of addiction. Holton says she does have a few clients who attend 12 Step meetings.
“It’s been an interesting mix from the clients who do go to the 12 Step meetings,” Holton says. “They’ve shared that they don’t know of many people getting outpatient treatment and wish that some of them were. It’s almost a one-or-the-other scenario in my area.”
Holton says one client in particular shared an interesting observation: Those who seemed to benefit the most from the 12 Steps likely didn’t have guidance or mentoring throughout their lives.
“His vantage point was that for the folks who already have that moral compass in place, who have had good relationships and support, the 12 Steps don’t always feel as welcoming,” Holton says.
A small percentage of survey respondents—2.1%—said they felt the 12 Steps seem like a cult. Fried says he can understand that perspective.
“Are there people who have taken basic tenets of it and turned it into a cult-like atmosphere and used it to weigh over people? Yes,” Fried says.
“I liken it to any faith-based approach. There are synagogues, temples, churches and mosques that are abusive. But if you look at the core teachings of these faiths, they have good value. The same is true of the 12 Steps.”
Going to the MAT
On the subject of abusing otherwise good parts of treatment, Fried, who has 16 years of experience in the field and has been full-time since 2008, expresses similar concern about medication-assisted treatment. He says he is concerned that doctors who prescribe buprenorphine to the full 275 patients for which they are licensed lack the capacity to devote themselves to other aspects of care.
“They have time to do a three-point checklist and send you on your way with another tab and another month’s prescription,” Fried says. “I believe MAT is a good thing, but not the way it’s practiced a lot in the world around me.
“It’s a disservice to tell someone that’s all they need. It’s supposed to be, according to SAMHSA, in conjunction with therapy so they can learn to live life eventually without it. If you start MAT without any vision or thoughts toward an endgame, you’re doing a disservice.”
Fried’s views are in line with a strong majority of survey respondents: 75.9% say MAT is effective when it is provided in conjunction with counseling.
Jordan echoed Fried’s sentiments in that medication-assisted treatment offers a greater chance at quality long-term recovery—as long as the provider can get the patient stabilized to a point where they can eventually be weaned off the medication.
Holton says she does not have any clients using medication-assisted therapy and that early in her career, she was skeptical of MAT overall. Today, she says she remains on the fence as to whether MAT should be a first option in treatment for substance use disorders, but for those who have had several instances of recurrence, medication is worth trying to create a better foundation for recovery.
“I just want the field to be wise about how we’re using it and that we’re not exploiting people because of the money aspect of it,” she says.
Tom Valentino is Senior Editor of Addiction Professional.
Student loan debt forgiveness programs a non-starter for many
Of the 258 respondents to the Quality of Life Survey who said they have outstanding student loan debt, the median amount reported was $50,000, with more than 20% claiming debt of at least $100,000. This marked a significant jump from the previous year’s survey, in which the median amount of outstanding debt reported was $28,259.
Of the clinicians who spoke with Addiction Professional for this story, Robert Jordan told the magazine he has no outstanding debt, while Lyle Fried says he has $10,000 left to pay off. Jessica Holton, meanwhile, has nearly $25,000 to go. Holton says at one time she considered pursuing loan forgiveness programs through not-for-profit work arrangements, but ultimately found that few options existed in her area.
“The few times I did look into it, I didn’t meet the criteria,” she says.
